Hormonal stimulation reduces numbers and impairs function of human uterine natural killer cells during implantation

STUDY QUESTION

How does an altered maternal hormonal environment, such as that seen during superovulation with gonadotropins in ART, impact human uterine immune cell distribution and function during the window of implantation?

SUMMARY ANSWER

Hormonal stimulation with gonadotropins alters abundance of maternal immune cells including uterine natural killer (uNK) cells and reduces uNK cell ability to promote extravillous trophoblast (EVT) invasion.

WHAT IS KNOWN ALREADY

An altered maternal hormonal environment, seen following ART, can lead to increased risk for adverse perinatal outcomes associated with disordered placentation. Maternal immune cells play an essential role in invasion of EVTs, a process required for proper establishment of the placenta, and adverse perinatal outcomes have been associated with altered immune cell populations. How ART impacts maternal immune cells and whether this can in turn affect implantation and placentation in humans remain unknown.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was carried out between 2018 and 2021 on 51 subjects: 20 from natural cycles 8 days after LH surge; and 31 from stimulated IVF cycles 7 days after egg retrieval.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrial biopsies and peripheral blood samples were collected during the window of implantation in subjects with regular menstrual cycles or undergoing superovulation. Serum estradiol and progesterone levels were measured by chemiluminescent competitive immunoassay. Immune cell populations in blood and endometrium were analyzed using flow cytometry. uNK cells were purified using fluorescence-activated cell sorting and were subjected to RNA sequencing (RNA-seq). Functional changes in uNK cells due to hormonal stimulation were evaluated using the implantation-on-a-chip (IOC) device, a novel bioengineered platform using human primary cells that mimics early processes that occur during pregnancy in a physiologically relevant manner. Unpaired t-tests, one-way ANOVA, and pairwise multiple comparison tests were used to statistically evaluate differences.

MAIN RESULTS AND THE ROLE OF CHANCE

Baseline characteristics were comparable for both groups. As expected, serum estradiol levels on the day of biopsy were significantly higher in stimulated (superovulated) patients (P = 0.0005). In the setting of superovulation, we found an endometrium-specific reduction in the density of bulk CD56+ uNK cells (P < 0.05), as well as in the uNK3 subpopulation (P = 0.025) specifically (CD103+ NK cells). In stimulated samples, we also found that the proportion of endometrial B cells was increased (P < 0.0001). Our findings were specific to the endometrium and not seen in peripheral blood. On the IOC device, uNK cells from naturally cycling secretory endometrium promote EVT invasion (P = 0.03). However, uNK cells from hormonally stimulated endometrium were unable to significantly promote EVT invasion, as measured by area of invasion, depth of invasion, and number of invaded EVTs by area. Bulk RNA-seq of sorted uNK cells from stimulated and unstimulated endometrium revealed changes in signaling pathways associated with immune cell trafficking/movement and inflammation.

LIMITATIONS, REASONS FOR CAUTION

Patient numbers utilized for the study were low but were enough to identify significant overall population differences in select immune cell types. With additional power and deeper immune phenotyping, we may detect additional differences in immune cell composition of blood and endometrium in the setting of hormonal stimulation. Flow cytometry was performed on targeted immune cell populations that have shown involvement in early pregnancy. A more unbiased approach might identify changes in novel maternal immune cells not investigated in this study. We performed RNA-seq only on uNK cells, which demonstrated differences in gene expression. Ovarian stimulation may also impact gene expression and function of other subsets of immune cells, as well as other cell types within the endometrium. Finally, the IOC device, while a major improvement over existing in vitro methods to study early pregnancy, does not include all possible maternal cells present during early pregnancy, which could impact functional effects seen. Immune cells other than uNK cells may impact invasion of EVTs in vitro and in vivo, though these remain to be tested.

WIDER IMPLICATIONS OF THE FINDINGS

These findings demonstrate that hormonal stimulation affects the distribution of uNK cells during the implantation window and reduces the proinvasive effects of uNK cells during early pregnancy. Our results provide a potential mechanism by which fresh IVF cycles may increase risk of disorders of placentation, previously linked to adverse perinatal outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

Research reported in this publication was supported by the University of Pennsylvania University Research Funding (to M.M.), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P50HD068157 to M.M., S.S., and S.M.), National Center for Advancing Translational Sciences of the National Institutes of Health (TL1TR001880 to J.K.), the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia Research Institute (to S.M.G.), and the National Institute of Allergy and Infectious Diseases (K08AI151265 to S.M.G.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. All authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Urinary neutrophil gelatinase-associated lipocalin after kidney transplantation: is it a good biomarker to assess delayed graft function?

Delayed graft function (DGF) is a common complication after transplantation. Its incidence is increased among patients receiving a graft from an expanded-criteria donor. Urinary neutrophil gelatinase-associated lipocalin (uNGAL), an acute kidney injury marker, could in the first days after transplantation be an early marker of DGF. We collected urine samples from 38 renal transplant recipients on days 1, 3, 6, and 10 post-transplantation, and months 1 and 6 creatinine to determine uNGAL, serum creatinine, Cystatin C, and albumin/creatinine ratio. We divided the patients into 2 groups, based on whether they developed DGF. We observed that mean uNGAL concentrations, Cystatin C, serum creatinine, and albumin/creatinine ratio were significantly lower in the non-DGF cohort on all measured days. uNGAL at day 3 showed a positive correlation with serum creatinine at day 10 (R = 0.58; P < .00) and day 30 (R = 0.57; P = .016) as well as with the length of hospital stay (r = 0.47; P < .00). Receiver operating characteristic analyses performed to assess the potential of uNGAL to predict DGF showed an area under the curve for day 3 of uNGAL of 0.917 (confidence interval [CI], 0.79-1.00; P = .00), with an optimal cutoff level of 124 ng/mL, sensitivity of 80% (CI, 62%-97%), and specificity of 83% (62%-104%; P = .001). In the first days after transplantation, uNGAL could be an early marker of DGF, providing additional information to standard biomarkers and potentially helping clinicians to take early measures to mitigate DGF.

Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur, Malaysia

This research aimed to determine HIV prevalence, risk behaviour and knowledge of transmission methods among men who have sex with men (MSM) in Kuala Lumpur, Malaysia. Venue-day-time sampling (VDTS) was applied to identify venues where men congregate to solicit sex from other men. Participants recruited from clubs, massage parlours, saunas and one park self-completed a computerized behavioural questionnaire, were administered an oral rapid HIV test and given the opportunity to return later to receive full counselling and learn their HIV status. A total of 517 men were enrolled into the study. The majority were Malays (47.0%) and Chinese (43.7%). Twenty tested HIV positive (3.9%). Significant predictors of HIV infection included having unprotected anal sex with a casual partner (44.9% of participants, odds ratio [OR] = 2.99; 95% confidence interval [CI] 1.13-7.90; P = 0.027), having unprotected receptive anal sex (27.9%, OR = 2.71; 95% CI 1.10-6.54; P = 0.030) and having group sex (33.3%, OR = 3.95; 95% CI 1.55-10.09; P = 0.004). One in five participants (20.1% and 19.5%) did not believe that HIV could be transmitted through insertive or receptive anal sex, respectively. Risk behaviour is high and knowledge of HIV transmission methods was low among MSM in Kuala Lumpur. Future prevention efforts should focus on providing risk reduction education to this community.

Ambulatory blood pressure monitoring in renal transplant patients: should it be routinely performed?

INTRODUCTION

Arterial hypertension is common among kidney transplant patients. It increases cardiovascular risk and is a factor for progression of renal failure. Our objective was to perform ambulatory blood pressure monitoring (ABPM) in renal transplant patients with office hypertension.

METHODS

Patients were divided into 2 groups according to their mean ABPM blood pressures with treatment: well-controlled hypertension (blood pressure [BP] <130/85 mmHg), and poorly controlled hypertension (BP>130/85 mmHg). A "nondipper pattern" was defined as a decrease of <10% or an increase, and a "raiser pattern," in which mean blood pressure was greater during the nocturnal than the diurnal period. "White coat effect" was considered when the mean of 3 BP measurements in the clinic was >140/90 mmHg among well-controlled hypertensive patients as documented by ABPM.

RESULTS

ABPM was performed in 53 patients: 25 (47%) "well-controlled hypertensives" and 28 (53%) "poorly controlled hypertensives." Of the latter, 24 (85%) showed a nondipper or raiser pattern with only 4 revealing dipper patterns. We compared well-controlled with poorly controlled hypertensives. The latter cohort were older (54.4±9.3 vs 45.5±13.8 years; P=.009), received grafts from older donors (56.7±15.0 vs 45.8±17 years; P=.02); had worse renal function measured by serum creatinine (1.7±0.5 vs 1.4±0.4 mg/dL, P=.03) or the Modification of Diet in Renal Disease (MDRD)=4 formula (41.8±14.0 vs 55.4±20.5 mL/min/1.73 m2; P=.009), and displayed more proteinuria (0.30±0.33 vs 0.18±0.10 g/d, P=.08). Nondipper or raiser patients showed a higher mean body mass index (27.1 vs 21.7 kg/m2; P=.04). Among 25 well-controlled patients, 11 presented "white coat phenomenon."

CONCLUSION

We observed an important "white coat" effect, a large prevalence of uncontrolled nocturnal hypertension, and a small but important incident of "masked hypertension." Factors related to hypertension control were patient age, donor age, renal function, induction use, and proteinuria.

Carbon monoxide re-breathing during low-flow anaesthesia in infants and children

BACKGROUND

Carbon monoxide (CO) has been detected within anaesthesia breathing systems. One potential source in this setting is exhaled endogenous CO. We hypothesized that CO is re-breathed during low-flow anaesthesia (LFA) in infants and children.

METHODS

Twenty children (age 2 months-7 yr) undergoing general anaesthesia were evaluated in a prospective observation study. LFA was established for 60 min followed by high-flow anaesthesia (HFA) for the next 60 min. Exhaled and inspired CO were measured every 5 min within the breathing circuit. Carboxyhaemoglobin (COHb%) was measured at baseline, at 60 min, after LFA, and at 120 min, after HFA.

RESULTS

CO concentrations increased during LFA. Inspired CO peaked at 14 ppm. During HFA, exhaled CO levels remained constant whereas inspired CO decreased markedly. Exhaled and inspired CO during HFA differed significantly from LFA. The trajectory of change in exhaled and inspired CO was most closely associated with the fresh-gas flow (FGF):minute ventilation ratio. COHb% significantly increased in children <2 yr of age at 60 min after LFA and remained increased.

CONCLUSIONS

LFA increased exhaled and inspired CO and increased COHb% in children <2 yr of age. Thus, LFA resulted in re-breathing of exhaled CO and exposure, especially in the youngest children. Re-breathing exhaled gas during LFA could pose a risk for an acute CO exposure in patients who have elevated COHb and high baseline levels of exhaled CO. If practitioners match or exceed minute ventilation with FGF to avoid LFA, CO re-breathing can be limited.

Renal allografts from donors older than 70 years are useful for single transplantation

Kidney transplantation has been related in elderly recipients to a greater longevity compared with dialysis. Due to the scarcity of donors, transplantation of older patients depends on the acceptance of older donors. We compared the characteristics and evolution of transplants from donors >or=70 years (n = 53) with those from donors >55-<70 years (n = 201). Group D >or=70 included older recipients (65.37 +/- 4.9 vs 55.92 +/- 9.66 years; P = .000) and more women (62.3% vs 45.3%; P = .02), with more peripheral arterial disease (10.9% vs 2.4%; P = .011). No differences in donor characteristics were observed. Induction treatment with thymoglobulin or basiliximab was more common in D >or=70 (81.1% vs 57.3%; P = .006), with no differences in other immunosuppressive drugs. The incidence of delayed graft function (DGF) was similar (P = .82), with a trend to a lower incidence of acute rejection episodes among D>or=70 (11.8% vs 22.5%; P = 0.09). Serum creatinine and proteinuria levels did not differ during follow-up (P > .05). Patients in D >or=70 displayed more episodes of urinary sepsis (19.1% vs 6.4%; P = .008), but no differences were observed in cytomegalovirus (CMV) infection (P = .629), neoplasia (P = .118), ischemic cardiopathy (P = .642), or hospital readmission due to infections (P = .567). Graft survivals at 5 years were 70% and 75% (P = .279) among groups D >or=70 and D>55-<70, respectively, and patient survivals at 5 years were 88% and 88% (P = .63), respectively. In conclusion, our study showed that selected kidneys from donors older than 70 years were followed with excellent graft and patient survivals, permitting older patients on renal replacement therapy to benefit from renal transplantation.

Treatment of renal transplant failure

INTRODUCTION

Among graft failures beyond months, we performed progressive reduction and complete withdrawal of immunosuppressive drugs and steroids over a period of 6 months.

PATIENTS AND METHODS

We analyzed the treatment and complications associated with all late allograft failures in 34 patients (8.19%) out of 415 patients transplanted from November 1996 to November 2006.

RESULTS

In 21 patients (61.8%), the progressive reduction of immunosuppressive treatment was effective and well tolerated; however, in 13 patients (38.2%) there was rejection of the allograft at 10.74 +/- 8.95 months (0.77-34.80) after the failure. With the reintroduction of these drugs, the rejection was controlled in seven patients, but in the other six we had to embolize the allograft, which had to be repeated in one case. Embolization was well tolerated, but in one case there was migration of one coil to the femoral artery. One patient treated with drug withdrawal experienced emphysematous pyelonephritis after repeated urinary infections, requiring a nephrectomy. Thirteen (38.2%) of the patients with late failures have been admitted for a second transplant; five of them showed HLA sensitization.

CONCLUSIONS

Conservative treatment with progressive withdrawal of immunosuppression was effective and well tolerated in two-thirds of the patients with late renal allograft failure, but one-third of the patients rejected the graft and needed allograft embolization. Infection of the graft and HLA sensitization can complicate the course of these patients.

[On-line sequential hemodiafiltration (HDF-OL-S): a new therapeutic option]

BACKGROUND

on line haemodiafiltration provides the greatest clearance for low and high-molecular weight uremic toxins, which is associated with a lower risk of mortality in our patients. Nowadays, there's increasing evidence about the need of achieving at least 20 litters ultrafiltration in postdilution mode and 70% reduction of beta-2-Microglobulin (B2M), however it requires a vascular access's high blood flow. Unfortunately, we do not succeed in these objectives because of our patients being older, diabetic and with poor vascular access; in this situation high blood flows are more difficult to get at the expense of lower post-dilution exchange volumes. The aim of this study was to assess the efficiency of OL-S-HDF to obtain an equivalent ultrafiltration volume as 20 L in OL-postdilution-HDF (OL-P-HDF). OL-S-HDF initially begins in postdilution mode changing to predilution once the transmembrane pressure (TMP) reached 250 mmHg.

METHODS

we performed one high-flux HD session (HF-HD), one OL-P-HDF session and one OL-S-HDF session in each of the 16 adult patients who participated during 3 consecutive weeks. We compared the clearance rates of low and middle molecules such as urea, creatinine, B2M, myoglobulin and levels of albumin and haematocrit between the 3 different techniques. We measured the pre-filter pressure (PFP) by a manometer set before the dialyzer.

RESULTS

The main characteristics of the sessions are described in table N1. There wasn't significant difference in Kt/V, urea and creatinine removal between the three techniques. B2M and myoglobulin's clearance rates were significantly higher in both hemodiafiltration modes than in HF-HD (p=0.000), however we didn't find differences between OL-P-HDF and OL-S-HDF. There was a direct correlation between PFP and TMP along the sessions in every technique (p<0.05). We found that PFP was better than TMP to correlate with pre-dialysis levels of albumin and haematocrit and also with the haemoconcentration percentage at the end of the sessions.

CONCLUSIONS

This study confirms that OL-S-HDF is as good as OL-P-HDF and it could be a useful technique to treat patients with suboptimal access's blood flow to get to achieve ultrafiltration volumes within the objectives. PFP could offer extra information than TMP.

Benefits Derivated From Late Steroid Withdrawal in Renal Transplant Recipients

Because corticosteroids have adverse metabolic effects, inducing bone-mineral imbalance and contributing to infections among renal transplant recipients, many withdrawal trials have been attempted to reduce adverse events and improve quality of life. We retrospectively analyzed the safety and efficacy of late steroid withdrawal, after the first posttransplant year, among a selected group of kidney allograft recipients. In 42 low immunological risk allograft recipients, among 382 patients transplanted during a decade, corticosteroids were progressively reduced and completely withdrawn. The evolution of clinical and biochemical parameters after the withdrawal were analyzed. Corticosteroid withdrawal was performed as a mean of 52.16 +/- 28.41 months posttransplant, with subsequent follow-up without steroid treatment of 18.13 +/- 16.11 months. Comparing the most recent evaluation with the data previous to steroid withdrawal, patients showed a significant decreases in diastolic pressure (P = .039), total cholesterol (P = .000), and low-density lipoprotein cholesterol levels (P = .039), but not in triglyceride levels (P = .33). Body weight did not change (P = .77), but increased fasting glucose levels were noted (P = .03), in absence of new diagnosed diabetes mellitus. A significant reduction in cyclosporine Neoral (P = .01) or tacrolimus doses were detected (P = .01). At the last visit, serum creatinine in the whole group remained stable (P = .06). Only five patients showed an increase in serum creatinine more than 20% (from 1.44 +/- 0.41 to 1.94 +/- 0.45 mg/dL P = .04) and proteinuria did not increase (P = .94). No patient was diagnosed with a rejection episodes or required corticosteroid resumption. Graft and patient survivals were 100% at the end of follow-up. In conclusion, our data showed that late corticosteroid withdrawal in renal transplant recipients of low immunological risk is safe and is followed by an improvement in their metabolic profile and in blood pressure.

Kidney Transplantation With Grafts From Non–Heart-Beating Donors

We analyzed the function and outcome of 16 kidney transplants performed in our hospital from non-heart-beating donors who were harvested at other hospitals. The cold ischemia times were longer and the delayed graft function rates higher. However, graft function was no different from that of kidneys from heart-beating donors. This experience has encouraged us to use this type of donor to reduce the transplant waiting list.

Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence

A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.

Expression and activity of mutants of fasciculin, a peptidic acetylcholinesterase inhibitor from mamba venom

Fasciculin, a selective peptidic inhibitor of acetylcholinesterase, is a member of the three-fingered peptide toxin superfamily isolated from snake venoms. The availability of a crystal structure of a fasciculin 2 (Fas2)-acetylcholinesterase complex affords an opportunity to examine in detail the interaction of this toxin with its target site. To this end, we constructed a synthetic fasciculin gene with an appropriate leader peptide for expression and secretion from mammalian cells. Recombinant wild-type Fas2, expressed and amplified in Chinese hamster ovary cells, was purified to homogeneity and found to be identical in composition and biological activities to the venom-derived toxin. Sixteen mutations at positions where the crystal structure of the complex indicates a significant interfacial contact point or determinant of conformation were generated. Two mutants of loop I, T8A/T9A and R11Q, ten mutants of the longest loop II, R24T, K25L, R27W, R28D, H29D, DeltaPro30, P31R, K32G, M33A, and V34A/L35A, and two mutants of loop III, D45K and K51S, were expressed transiently in human embryonic kidney cells. Inhibitory potencies of the Fas2 mutants toward mouse AChE were established, based on titration of the mutants with a polyclonal anti-Fas2 serum. The Arg27, Pro30, and Pro31 mutants each lost two or more orders of magnitude in Fas2 activity, suggesting that this subset of three residues, at the tip of loop II, dominates the loop conformation and interaction of Fas2 with the enzyme. The Arg24, Lys32, and Met33 mutants lost about one order of magnitude, suggesting that these residues make moderate contributions to the strength of the complex, whereas the Lys25, Arg28, Val34-Leu35, Asp45, and Lys51 mutants appeared as active as Fas2. The Thr8-Thr9, Arg11, and His29 mutants showed greater ratios of inhibitory activity to immunochemical titer than Fas2. This may reflect immunodominant determinants in these regions or intramolecular rearrangements in conformation that enhance the interaction. Of the many Fas2 residues that lie at the interface with acetylcholinesterase, only a few appear to provide substantial energetic contributions to the high affinity of the complex.

Soluble monomeric acetylcholinesterase from mouse: expression, purification, and crystallization in complex with fasciculin

A soluble, monomeric form of acetylcholinesterase from mouse (mAChE), truncated at its carboxyl-terminal end, was generated from a cDNA encoding the glycophospholipid-linked form of the mouse enzyme by insertion of an early stop codon at position 549. Insertion of the cDNA behind a cytomegalovirus promoter and selection by aminoglycoside resistance in transfected HEK cells yielded clones secreting large quantities of mAChE into the medium. The enzyme sediments as a soluble monomer at 4.8 S. High levels of expression coupled with a one-step purification by affinity chromatography have allowed us to undertake a crystallographic study of the fasciculin-mAChE complex. Complexes of two distinct fasciculins, Fas1-mAChE and Fas2-mAChE, were formed prior to the crystallization and were characterized thoroughly. Single hexagonal crystals, up to 0.6 mm x 0.5 mm x 0.5 mm, grew spontaneously from ammonium sulfate solutions buffered in the pH 7.0 range. They were found by electrophoretic migration to consist entirely of the complex and diffracted to 2.8 A resolution. Analysis of initial X-ray data collected on Fas2-mAChE crystals identified the space group as P6(1)22 or P6(5)22 with unit cell dimensions a = b = 75.5 A, c = 556 A, giving a Vm value of 3.1 A3/Da (or 60% of solvent), consistent with a single molecule of Fas2-AChE complex (72 kDa) per asymmetric unit. The complex Fas1-mAChE crystallizes in the same space group with identical cell dimensions.

Activity of an intracellular lymphocyte stimulator is independent of G-protein interactions, [Ca2+]i elevation, phosphoinositide hydrolysis, and protein kinase C translocation

We have evaluated potential molecular mechanisms by which a group of synthetic lymphokine-like molecules, the 7,8-disubstituted guanine ribonucleosides, acts on second messenger pathways to augment the responses of murine B lymphocytes. Despite its extensive structural homology with GTP, 7-methyl-8-oxoguanosine (7-Me-8-oGuo), a prototypical disubstituted nucleoside, does not inhibit the binding of guanosine 5'-3-O-(thio)triphosphate either to purified G-proteins, or to G-proteins in situ in the plasma membrane. In contrast to anti-IgM antibodies, 7-Me-8-oGuo fails to induce elevation of intracellular free calcium in B lymphocytes. It does not elicit enhanced production of inositol phosphates in either unfractionated or large, cycling B cells (the cells on which it acts preferentially). It is unable to modify the cellular distribution or activity of protein kinase C, whereas phorbol 12-myristate 13-acetate, anti-IgD antibodies, and lipopolysaccharide do activate protein kinase C. Inhibitors of protein kinase C activity diminish stimulation of mRNA transcription by anti-IgD antibodies and lipopolysaccharide but not by 7-Me-8-oGuo. These data demonstrate that 7-Me-8-oGuo either uses a pathway distinct from that mediated by G-proteins, intracellular free calcium, inositol phosphates, and protein kinase C, or else bypasses the early events of this pathway, activating the cell at a point beyond their involvement. In either event, these nucleosides represent the only class of activator to date that is capable of driving B cell proliferation and differentiation without involvement of protein kinase C.

Clinical case management: definition, principles, components

The burgeoning field of case management for long-term psychiatric patients has been handicapped by a lack of conceptual models that delineate the diverse activities of case managers. Based on the actual practice of case management, the author outlines a model of clinical case management that moves beyond the view of the case manager as a systems coordinator, service broker, or supportive companion. Using a contemporary biopsychosocial model of mental illness, the clinical case management model integrates the clinical acumen, personal involvement, and environmental interventions needed to address the overall maintenance of the patient's physical and social environment. Clinical case management involves 13 distinct activities, including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psychoeducation, and crisis intervention.

Expressed emotion in families: a critical review

Research on expressed emotion in the families of schizophrenic patients has seemed to offer a new perspective on environmental factors that cause relapse in schizophrenia. A review of the literature, however, reveals that while expressed emotion may predict relapse, there is no evidence that it causes relapse. Nor does the evidence support the continued linkage of the three components of expressed emotion--criticism, hostility, and emotional overinvolvement--in a single global variable. The authors also question the clinical significance of expressed emotion ratings and believe that treatment strategies based on them tend to blame relatives for the patient's continuing difficulties. They suggest that clinicians assess family responses in the context of the patient's behavior and life situation before helping families develop more effectual coping strategies.

The relationship of weight loss to surface roughness of composite resins from simulated toothbrushing

This study was designed to measure percentage of weight loss during simulated toothbrushing of five different composite resins. The surface roughness of each composite resin was also measured after each year of simulated toothbrushing for a period of 5 years. The following conclusions were reached: 1. Despite the loss of toothbrush efficiency, all composite resins tested tended to have a decreasing wear rate with the increasing time of toothbrushing. 2. Profile (with a soft filler) and Isopast (with a microsized filler) showed the greatest resistance to abrasion and retained the smoothest surface. 3. Prestige, which demonstrated the greatest percent weight loss, also has a soft barium filler. Loss of the filler as an alkaline reaction in water due to soluble barium compounds may cause the binder to release filler particles prematurely.

Facilitating a therapeutic milieu in the families of schizophrenia

For many years, mental health professionals and the families of schizophrenics have coexisted in an atmosphere of mutual distrust and hostility. In this paper, we would like to present some of our experiences in creating a more productive relationship with the families of long-term schizophrenic clients in an aftercare setting. We have found that it is possible to engage these families as allies in the long and difficult process of psychodynamically oriented psychotherapy and resocialization. In many instances, these families actually provide several of the major functions of a vital therapeutic milieu, including containment, support, and structure (Gunderson, 1978).

Evaluation of insertion methods for composite resin restorations

Laboratory studies were carried out to determine if there was one superior method to achieve the most intimate contact of a composite resin with its cavity walls. Three dentists restored 48 teeth by eight different techniques with two different composite resins. Photomicrographs showed very little difference in the size of the gap between tooth and composite resin regardless of which method was employed. The gap was smallest in the cavosurface area and greatest at the axio-occlusal line angle.